Economic Evidence Supports CBT-I for Insomnia, but Research Gap Persists for Hypersomnia

Cognitive behavioral therapy for insomnia (CBT-I), delivered either face-to-face or digitally, offers good value for money compared with no treatment and, in many cases, with pharmacotherapy, according to a recent systematic review of economic evaluations.¹ However, the analysis also underscores major gaps in the literature, including a complete absence of cost-effectiveness studies for hypersomnia treatments and limited data in adolescents and low- and middle-income countries.

Insomnia and hypersomnia are associated with substantial health care utilization, reduced productivity, and broader societal costs. Previous research has shown that both are associated with substantial economic burden, with insomnia alone estimated to cost US society $15.1 billion annually—including health care use, productivity losses, informal care, workplace injuries, and motor vehicle accidents—exceeding the costs attributed to obstructive sleep apnea or restless legs syndrome.²

To better understand the economic value of available treatments, investigators conducted a systematic search of MEDLINE, PsycINFO, CINAHL, EconLit, Embase, and Health Technology Assessment websites from database inception through February 18, 2025.¹ Eligible studies included full economic evaluations and return-on-investment (ROI) analyses of interventions targeting insomnia or hypersomnia in individuals 12 years and older. Study quality was assessed using the Drummond checklist, and findings were synthesized narratively.

Among 28 studies meeting inclusion criteria, 26 focused on adults or older adults with insomnia, 2 examined adolescents with insomnia, and none evaluated treatments for hypersomnia. The number of economic evaluations has grown over time: 7 were published before 2011, 9 between 2011 and 2020, and 12 from 2020 to 2025, yet only 1 study was conducted in a low- or middle-income country.

Across high-quality trial-based evaluations, CBT-I, whether delivered face-to-face (F2F) or digitally, and pharmacotherapy were generally cost-effective compared with inactive controls from both health care and societal perspectives. ROI analyses, primarily focused on CBT-I, frequently found the therapy to be cost-saving.

Digital CBT-I emerged as particularly promising. Multiple studies comparing digital with F2F CBT-I, reflecting growing interest in scalable, internet-based mental health interventions, found that digital formats often generated health care and societal cost savings. These savings were more pronounced when analyses adopted a societal perspective that incorporated productivity losses, informal care, and accident-related costs. In several cases, the investigators found that digital CBT-I shifted from being cost-effective to cost-saving when broader societal costs were included.

However, the study noted uncertainty remains regarding comparative effectiveness. Self-help digital CBT-I showed variable health outcomes compared with F2F CBT-I, ranging from slightly less effective to equivalent. Therapist-guided digital CBT-I more consistently achieved favorable cost-effectiveness results, particularly under a societal perspective, and aligns with prior evidence that clinician involvement improves adherence and remission rates.

Pharmacotherapy was also generally cost-effective relative to inactive controls, although most economic evaluations did not account for risks such as dependence or tolerance. Complementary and alternative medicine interventions were underrepresented, and their cost-effectiveness remains unclear.

Time horizon and analytic perspective substantially influenced findings, the authors observed. More than half of studies had time horizons shorter than 7 months, largely due to trial-based designs. Only 3 model-based evaluations extended beyond 1 year and suggested sustained cost-effectiveness of CBT-I and pharmacotherapy. Broader modeling over longer time frames could better capture downstream benefits, including reduced accidents and falls—outcomes often omitted from current analyses.

Health outcomes were typically measured using quality-adjusted life years (QALYs) and improvements in Insomnia Severity Index (ISI) scores. While ISI improvements were frequently statistically significant, QALY gains were less consistently detected, particularly when using EQ-5D instruments. Differences in utility measurement tools and scoring algorithms may explain these discrepancies.

Importantly, several studies evaluated CBT-I as an adjunct to usual care for comorbid mental health conditions such as depression and schizophrenia. In these populations, adding CBT-I was often dominant or cost-effective, with prior evidence suggesting benefits for both insomnia and psychiatric symptoms.

The authors concluded that current evidence supports CBT-I as a value-for-money first-line treatment for insomnia. Policy makers may consider strengthening guideline recommendations and expanding access, including investment in clinician training and digital platforms. Still, research gaps remain, particularly for hypersomnia, adolescents, low-resource settings, and long-term outcomes.

References

1. Le PH, Le LK, Le DQ, Rajaratnam SMW, Mihalopoulos C. A systematic review of economic evaluations on interventions targeting insomnia or hypersomnia. Appl Health Econ Health Policy. 2026;24(1):87-110. doi:10.1007/s40258-025-00997-2
2. Streatfeild J, Smith J, Mansfield D, Pezzullo L, Hillman D. The social and economic cost of sleep disorders. Sleep. 2021;44(11):zsab132. doi:10.1093/sleep/zsab132.